10 - World Journal of Gastroenterology

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Online Submissions: http://www.wjgnet.com/1007-9327office wjg@wjgnet.com doi:10.3748/wjg.v17.i10.1267 World J Gastroenterol 2011 March 14; 17(10): 1267-1275 ISSN 1007-9327 (print) ISSN 2219-2840 (online) © 2011 Baishideng. All rights reserved. ORIGINAL ARTICLE Portal vein thrombosis and arterioportal shunts: Effects on tumor response after chemoembolization of hepatocellular carcinoma Thomas J Vogl, Nour-Eldin Nour-Eldin, Sally Emad-Eldin, Nagy NN Naguib, Joerg Trojan, Hans Ackermann, Omar Abdelaziz Thomas J Vogl, Nour-Eldin Nour-Eldin, Nagy NN Naguib, Joerg Trojan, Hans Ackermann, Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany Sally Emad-Eldin, Omar Abdelaziz, Diagnostic and Interventional Radiology Department, Cairo University Hospital, Cairo, Egypt Author contributions: Vogl TJ, Nour-Eldin NE and Abdelaziz O contributed equally to this work; Vogl TJ, Nour-Eldin NE and Abdelaziz O designed research; Vogl TJ, Nour-Eldin NE and Abdelaziz O performed research; Emad-Eldin S, Naguib NNN, Trojan J contributed new analytic tools; Vogl TJ, Nour-Eldin NE, Abdelaziz O, Emad-Eldin S, Naguib NNN, Trojan J and Ackermann H analyzed data; and Vogl TJ, Nour-Eldin NE and Abdelaziz O wrote the paper. Correspondence to: Dr. Nour-Eldin Nour-Eldin, MD, Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe University Hospital, Theodor-Stern-Kai Street 7, 60590 Frankfurt am Main, Germany. nour410@hotmail.com Telephone: +49-69-63017278 Fax: +49-69-63017258 Received: September 14, 2010 Revised: November 11, 2010 Accepted: November 18, 2010 Published online: March 14, 2011 Abstract AIM: To evaluate the effect of portal vein thrombosis and arterioportal shunts on local tumor response in advanced cases of unresectable hepatocellular carcinoma treated by transarterial chemoembolization. METHODS: A retrospective study included 39 patients (mean age: 66.4 years, range: 45-79 years, SD: 7) with unresectable hepatocellular carcinoma (HCC) who were treated with repetitive transarterial chemoembolization (TACE) in the period between March 2006 and October 2009. The effect of portal vein thrombosis (PVT) (in 19 out of 39 patients), the presence of arterioportal shunt (APS) (in 7 out of 39), the underlying liver pathology, Child-Pugh score, initial tumor volume, number of tumors and tumor margin definition on imaging were correlated with the local tumor response after TACE. The initial and end therapy local tumor responses were evaluated according to the response evaluation criteria in solid tumors (RECIST) and magnetic resonance imaging volumetric measurements. RESULTS: The treatment protocols were well tolerated by all patients with no major complications. Local tumor response for all patients according to RECIST criteria were partial response in one patient (2.6%), stable disease in 34 patients (87.1%), and progressive disease in 4 patients (10.2%). The MR volumetric measurements showed that the PVT, APS, underlying liver pathology and tumor margin definition were statistically significant prognostic factors for the local tumor response (P = 0.018, P = 0.008, P = 0.034 and P = 0.001, respectively). The overall 6-, 12- and 18-mo survival rates from the initial TACE were 79.5%, 37.5% and 21%, respectively. CONCLUSION: TACE may be exploited safely for palliative tumor control in patients with advanced unresectable HCC; however, tumor response is significantly affected by the presence or absence of PVT and APS. © 2011 Baishideng. All rights reserved. Key words: Hepatocellular carcinoma; Transarterial chemoembolization; Portal; Shunt; Thrombosis Peer reviewer: Satoshi Mamori, MD, PhD, Department of Gastroenterology and Hepatology, Shinko Hospital, 1-4-47 Wakihama-cho, Chuo-ku, Kobe, Hyogo 651-0072, Japan Vogl TJ, Nour-Eldin NE, Emad-Eldin S, Naguib NNN, Trojan J, Ackermann H, Abdelaziz O. Portal vein thrombosis and arterioportal shunts: Effects on tumor response after chemoembolization of hepatocellular carcinoma. World J Gastroenterol 2011; 17(10): 1267-1275 Available from: URL: WJG|www.wjgnet.com 1267 March 14, 2011|Volume 17|Issue 10|
Vogl TJ et al . TACE therapy in advanced HCC http://www.wjgnet.com/1007-9327/full/v17/i10/1267.htm DOI: http://dx.doi.org/10.3748/wjg.v17.i10.1267 INTRODUCTION Hepatocellular carcinoma (HCC) is one of the most common neoplasms in the world and its incidence is increasing worldwide. It is associated with liver cirrhosis in 80% of cases and it is the leading cause of death among cirrhotic patients [1] . Liver resection and liver transplantation are curative therapeutic options [2] . Likewise, percutaneous ablative treatments such as percutaneous ethanol injection (PEI) [3] , radiofrequency ablation [4] , microwave ablation [5] or MR-guided laser-induced thermotherapy (LITT) [6] can also be applied as therapeutic options with curative potential. However, curative treatments are applicable in only 30%-40% of cases due to the presence of multifocal tumors or limited hepatic reserve at the time of diagnosis [7,8] . Transarterial chemoembolization (TACE) was introduced as a palliative local therapeutic option for the treatment of unresectable HCC. The goal of palliation is to control symptoms, improve life quality and prolong survival [8,9] . Different studies have investigated the predictors of survival after TACE and concluded that the prognosis is multifactorial, including the extent of the tumor at diagnosis and also the extent of liver injury [8,10,11] . The purpose of this study was to evaluate retrospectively the role of TACE in local tumor control of unresectable HCC and the effect of portal vein thrombosis (PVT) and arterioportal shunts (APS), as well as other associated pathological factors, on the local tumor response in advanced cases. MATERIALS AND METHODS Approval of this study was obtained from the institutional review board, and informed consent was obtained from all patients including approval of the protocol of treatment and the anonymous use of the data for research purposes. Patients The medical records of all patients who had unresectable hepatocellular carcinoma and who were treated with TACE between March 2006 and October 2009 were retrospectively evaluated. A total of 39 patients (33 males and 6 females) ranging in age from 45-79 years (mean: 66.4 years, SD: 7) with unresectable HCC were treated with repetitive TACE. The total number of sessions was 219, range: 1-17, mean: 5.6 sessions, SD: 3.7. Patient demographics, lesion pathology, treatment, and outcome data, including all histopathology reports and imaging studies, were collected from the electronic medical record archiving system and were subsequently analyzed. Special emphasis was placed on the stage of disease at the time of first embolization. The number, location and size of liver tumors were obtained by reevaluating the original CT Table 1 Patient and tumor criteria (n ) Total number 39 Age (yr) Range: 45-79, mean: 66.4, SD: 7 Gender (M:F) 33:6 Underlying liver pathology Hepatitis C virus 17 Hepatitis B virus 5 Alcoholic cirrhosis 7 Toxic cirrhosis 2 Cryptogenic cirrhosis 8 Child-Pugh Score Child A 27 Child B 12 Tumor number Solitary 20 Multiple 19 2 lesions 6 3 lesions 3 4 lesions 1 > 5 lesions 9 Tumor margin definition Well defined margin 20 Ill defined margin 19 Portal vein thrombosis 19 Main (partial thrombosis) 3 Main lobar branch 10 Segmental branch 6 A-P shunt 7 and magnetic resonance imaging (MRI) scans. The patient and tumor characteristics are summarized in Table 1. Inclusion and exclusion criteria All patients involved in the study were not eligible for surgical or local ablative therapies. The inclusion criteria of the study were: (1) Tumors of any size associated with portal vein thrombosis, either partial thrombosis of the main portal vein or segmental portal vein branch thrombosis; (2) Tumors associated with APS with or without PVT; (3) Large solitary tumors of more than 5 cm in maximal diameter, multinodular or bilobar tumors; and (4) Patients with Child-Pugh Scores between A and B. The exclusion criteria were: (1) Patients with poor performance status (Karnofsky index < 50%); (2) Nutritional impairment; (3) Presence of ascites; (4) Encephalopathy (5) High serum total bilirubin level (> 3 mg/dL); (6) Serum albumin level < 2.0 mg/dL; (7) Renal failure (serum creatinine level > 2 mg/dL); (8) Cardiovascular or respiratory failure; (9) Florid infection; (10) Main PV complete thrombosis; and (11) Extrahepatic tumor manifestation. Management protocol of the patients The protocol for management was decided by a multidisciplinary team composed of hepat ic surgeons, interventional radiologists, hepatologists and medical oncologists. The end point of TACE therapy was defined as stable disease for two successive sessions or disease progression. TACE technique TACE was performed with a treatment interval of 4- 6 wk. For patients with bilobar disease, the treatment was WJG|www.wjgnet.com 1268 March 14, 2011|Volume 17|Issue 10|
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